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94.10.18 萬芳醫院 - 魏賓慧

CASE CONFERENCE. Pediatric burn nutrition. 94.10.18 萬芳醫院 - 魏賓慧. 基本資料. 4 y/o 男性 入院日期： 94.7.30 PM 出院日期：94.8.26 C/C:Scald burn by boiled water this afternoon (before admission 2-3 hrs) Imp ： Scald burn, 2-3° , TBSA 35 % ( 背部 :18 % ) ( 手、腿、身體兩側：17% )

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94.10.18 萬芳醫院 - 魏賓慧

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  1. CASE CONFERENCE Pediatric burn nutrition 94.10.18萬芳醫院 - 魏賓慧

  2. 基本資料 • 4 y/o 男性 入院日期：94.7.30 PM 出院日期：94.8.26 • C/C:Scald burn by boiled water this afternoon (before admission 2-3 hrs) • Imp：Scald burn, 2-3° , TBSA 35 % ( 背部 :18 % ) ( 手、腿、身體兩側：17% ) • Height：100cm • Admission BW :15 kg • UBW : unknown

  3. Lab data

  4. Assessment – 生長發育評估 • 台灣地區0-6歲男孩身體發育曲線圖 體重：25-50 % 身高：25 %

  5. Assessment - 熱量.蛋白質需求 • 熱量需求評估 ref 3： (1) Curreri junior equation (age 4-18) : Basal Calories *W + 40*TBSA = 52 (age 4 )*15.7 + 40*35 = 2216 kcal (2) DRIs (> 4 Y/O) ： 1650 kcal / 30 g protein (3) Harris-Benedict equation BEE=66+13.7*15.7 + 5*100 –6.8*4 = 754 kcal • 蛋白質需要量： 15.7 kg * 1.5 –2 g = 24-32 g/ day

  6. Assessment - 進食量 Protein intake 8/6 8/13 8/17 1.65 g /kg BW 2.8 g /kg BW 4.3 g /kg BW 蛋白質攝取量以每公斤體重換算( BW : 15.7 kg)

  7. 2200 kcal 1650 kcal 754 kcal 熱量kcal Protein intake 院內訂餐SLD (8/1晚-8/2午點) 7/31 NPO with NG decompression 8/4 P : 鼓勵進食;濃縮熱量食物，冰淇淋;Forced feeding or PN support • 8/1 • remove NG tube • try milk then transfer to SLD 8/22 remove NG tube

  8. TF feeding dietary progress

  9. Assessment nutritional support adequacy 1. Wound healed TBSA : 35 % (7/30)  < 10 % (8/22) 2. Weight maintenance 3. Other parameters : no data allowed

  10. 營養介入遇到的問題點 1、 extraordinarily high energy expenditure , but poor appetites, poor oral intake : • 解決方案1：增加由口進食量 (1)詢問照顧者，個案的飲食喜好， 增加濃縮熱量來源 例如： 愛吃冰 suggest 冰淇淋 (2) 均衡營養品 : 例如：小滿力、小兒安素、兒童佳膳 • 解決方案2：增加營養供應途徑  PN support or forced Tube feeding

  11. 營養介入遇到的問題點 2. 燒傷面積大之個案胃排空差，NG tube 移除過快， 應等確定吃的不錯時，再移除管路 3. 幼兒胃容積小、燒傷個案胃排空差、時常嘔吐 增加濃縮營養來源 4. 幼兒對鈉的需要量是多少？ 5. 幼兒給予高蛋白時，應監測腎臟功能指數 6. 營養支持效率評估數值 8/15 建議監測 albumin

  12. 營養介入遇到的問題點 7. Forced tube feeding or PN？ • Enteral feeding is the preferred method for burn p’t  delivery immune stimulants  as effective prophylaxia against stress-induced gastropathy and gastrointestinal hemorrhage. • PN may be administrated (ref.1) (1) early excision and grafting  to avoid the frequent interruptions in EN support required for anesthesia (2) Persistent ileus. (3) High risk of aspiration.

  13. Na 3-4 mEq/kg/day 69-92mg/kg/day K 2-3 mEq/kg/day 78-117mg/kg/day Ca 60-90 mg/kg/day or 90-135 mEq/day ( 1800-2700mg) Mg 0.25-0.5 mEq/kg/day 3-6 mg/kg/day P 47-70 mEq/kg/day Electrolyte requirements in pediatric * Reference : Handbook of nutritional support (1997) pp.115

  14. Age Weight kg Sodium mg Chloride mg Potassium mg 0-5 month 4.5 120 180 500 6-11 month 8.9 200 300 700 1 year 11 225 350 1000 2-5 year 16 300 500 1400 6-9 year 25 400 600 1600 10-18 year 50 500 750 2000 > 18 year 70 500 750 2000 Estimated Minimum Requirements for sodium, chloride, and Potassium in healthy persons * Reference:Karuse’s Food, Nutrition, and diet therapy 11th edition PP.171

  15. redness Redness,blistering Skin and tissue destruction Bone Reference :Krause’s/Food, Nutrition, and Diet Therapy 11th PP.1072

  16. A real challenge for Medical Nutrition Therapy for burn • High energy and protein requirement • depending on the extent and depth of TBSA . over 50% TBSA, minimal increases in EE • Maximum caloric load is 2 * REE • Unable to take 75% of caloric needs orally, nocturnal tube feedings are indicated. (ref4) 2. gastric ileus • 當燙傷面積超過 20  ，特別容易出現 • 解決方案：灌食位置至小腸. 3. Anorexic

  17. A real challenge for Medical Nutrition Therapy for burn 4. Very early enteral feeding (within 4-12 hrs of hospitalization)  hypercatabolic response  catecholamine release  glucagon  BW loss  the hopspital length of stay

  18. Energy requirements- common methodsref.2 1. Curreri formula (1979) • 25 kcal * UBW(kg)+ 40 kcal *%TBSA burned (using a maximum of 50%burn) • Overestimates energy expenditure 2. BEE * 1.5 – 2 (adult and pediatric) 3. 40 –60 kcal / kg BW 4. Indirect calorimetry : more accurate for individual patients (take RQ twice weekly)

  19. Energy requirements- common methodsref.1 5. Ireton –Jones equation (burn +ventilatory) EEE = 1784 – 11A + 5W + 24G + 239T + 804B EEE:estimated energy expenditure(kcal/day) A:age W:weight kg G:gender (female:0 ; male:1) T:diagnosis of trauma (absent:0;present:1) B:diagnosis of burn (absent:0;present:1)

  20. Energy requirements for pediatric burn-1 • Its difficult to provide a formula to cover all age groups. It remains to be developed • commonly used formula 1. Galveston(1992) ref1 1800 kcal/m2 + 2200 kcal/m2of burn calculation of BSA(body surface area m2): HT(cm) * Wt(kg) 3600

  21. Energy requirements for pediatric burn-2 • Mayes and Warden ( 1996) (< 3 y/o) Mayes 1 (ref1)= 108 + 68W + 3.9 x % TBSA Mayes 2 = 179 + 66W + 3.2 x % 3rd degree burn *Patients 5 to 10 years of ageMayes 3 = 818 + 37.4W + 9.3 x % burnedMayes 4 = 950 + 38.5W + 5.9 x % 3rd degree burn W: *Weight (kg)

  22. Energy requirements for pediatric burn-3 Hildreth (1993) • 0-1 y/o : ( 2100 Kcal/m2 BSA + 1000 Kcal/m2 burn area )/day • 2~12 y/o : ( 1800 Kcal/m2 BSA + 1300 Kcal/m2 burn area )/day • 13-18 y/o : ( 1500 Kcal/m2 BSA + 1500 Kcal/m2 burn area )/day BSA: body surface areaM2 : meters squared

  23. Protein needs • 20-25 % of total calories (HBV) (REF1) Manual of clinicval dietetics . 5th. pp.359.ADA • Enteral or parenterl N : calorie ratio (REF2) 1:80-100 (adult) 1:130-150 (children) * tolerate protein depend on renal function and fluid balance

  24. Protein needs • Adult 1.5-3 g/ kg IBW (REF2) • Children 2.5-3 g/ kg BW (REF1) • Infant 3–4g/kgIBW/day (REF2) • Young children 1.2-2 g /kg (REF2) • Older children 1.5-2.5 g /kg (REF2)

  25. 三大營養素比例 (ref2) • 20-25 % Protein • 50% CHO • 25-30 % Fat (2-4 % EFAs )  Low fat have been shown to reduce rates of pneumonia and to speed healing.

  26. Vitamin • Vitamin needs increase but exact requirements have not been established. (some burn center routine protocol • Vit C 500 mg bid (collagen synthesis, immune function) (increased amount for w’d healing) • VitA 5000 IU/1000 kcal (for immune function , epithelialization)

  27. Manual of clinical dietetics . 5th. pp.360.ADA

  28. Vitamin and mineral recommendations (ref4)

  29. Assessment of energy and protein Adequacy (ref1) 1. wound healing ( occur only in an anabolic state) 2. graft take  wound healing and graft take delayed if weight loss exceeds 10 % of UBW 3. weight-change trend • The fluid gained during the resuscitation period is lost within 2 wks. • Weight maintenance is the goal for overweight p’t until the wound healed.

  30. Assess protein status (4) Nitrogen balance (NB) • nitrogen excretion decrease as wounds are healed or grafted or covered. • during the first 4 weeks,NB may be the most reflective measure in nutritional monitoring. • Estimate wound nitrogen losses

  31. Nitrogen output (ref4) = UUN + 2 (for children 0-4 y/o) = UUN + 3 (for children 5-10 y/o) = UUN + 4 (for children > 10y/o)

  32. nutritional assessment parameters • Albumin * Despite adequate caloric intake, hypoalbuminemia due to protein loss in burns occurs. (ref4) * Hypoalbuminemia continues until the burn w’d is less than 20 % BSA and hepatic protein synthesis is stored. (ref4) • Prealbumin • Retinol binding protein

  33. Reference 1. Krause’s/Food, Nutrition, and Diet Therapy 11th: Chapter 42/ Medical Nutrition Therapy for Metabolic Stress : Sepsis ,Trauma , Burns ,and Surgery pp.1071-1077 2. Sylvia escott-stump 4th edition : Nutrition and Dignosis-releated care pp.592-595 3. Clinical Nutrition:Enteral and Tube feeding. 3rd edition (1997) Chapter 19/ Enteral Nutrition in Burns pp. 339 4. Pediatric Enteral Nutrition (1994) :Enteral feeding in trauma and critical illness . pp.403-410

  34. 謝謝聆聽敬請指教

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